Journal of Athletic Training

2014;49(1):97101
doi: 10.4085/1062-6050-48.6.19
by the National Athletic Trainers Association, Inc
www.natajournals.org

case report

Frostbite in an Adolescent Football Player:

A Case Report
Michael Rivlin, MD*; Marnie King, OTR/L; Richard Kruse, DO;
Asif M. Ilyas, MD*
*Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, PA; Rothman Institute,
Philadelphia, PA; Department of Pediatric Orthopaedics, A.I. duPont Hospital, Wilmington, DE
Objective: To present the case of vascular compromise of a
finger from a confluent circumferential blister due to an
inappropriately applied commercial cold pack in a high school
athlete and to describe the mechanism of iatrogenic injury, acute
surgical management, rehabilitation, and pathophysiology of
frostbite and constriction injuries.
Background: A 17-year-old male football player presented
with a frostbite and constriction injury to the index finger
secondary to prolonged use of a cooling pack after a mild
traumatic injury to the digit. He developed a prolonged sensory
deficit from thermal injury, as well as acute vascular compromise
requiring urgent operative intervention.
Differential Diagnosis: Frostbite and constriction injury to
the index finger.
Treatment: Emergency surgical decompression and occupational therapy.

Uniqueness: Frostbite injuries can occur iatrogenically

because of inappropriate use of cooling devices or gel packs.
Fingers are commonly injured extremities that are particularly
susceptible to frostbite and compression injuries. To our
knowledge, no case of vascular compromise from the blister
constriction of digits has been reported.
Conclusions: Patients and their caregivers must be educated about how to properly use cooling devices. Clinicians
need to fully evaluate patients with iatrogenic frostbite injuries,
giving particular attention to neurovascular status, and must
recognize the need for surgical release of constriction syndrome
to prevent substantial morbidity.

nger were red and swollen. He did not experience any pain
at the time. He was evaluated that same day in a local
emergency department where radiographs of the nger
showed no bony injury or other condition, and he
subsequently was diagnosed with a low-grade sprain of
the right index nger. Per family report, the skin appeared
intact at the time. Generic discharge instructions for
managing sprains that detailed icing techniques were
provided. The patient did not apply any more cold to the
affected area after evaluation in the emergency department.
On the next day, he noticed that his right index nger and
the border half of his middle nger that was initially in
contact with the cooling gel pack were covered with a large
conuent blister. Later the same day, he presented to our
outpatient orthopaedic ofce for evaluation without an
appointment.
On encounter, he denied any pain but described
numbness in his index ngertip on his right hand. His
initial examination revealed a grossly dusky distal phalanx
of the right index nger with a well-demarcated, large,
conuent, circumferential tensile blister and hemorrhagic
areas over the volar aspect (Figure 1). The blister appeared
to create a tourniquet effect that prevented blood ow to the
ngertip. Most of the tissue involvement demonstrated
second-degree frostbite characterized by erythema and a
large conuent vesicle with clear uid content (Table).
Some areas, mainly over the palmar aspect of the nger,
had third-degree tissue involvement denoted by the
hemorrhagic area of blistering and dusky discoloration of

rostbite injuries are common in colder climates and

during winter recreational activities. The most
frequently involved areas are the distal and terminal
structures, such as the ngers, toes, nose, and ears. With the
wide acceptance of the rest, ice, compression, and elevation
protocol, iatrogenic frostbite has become a risk that cannot
be ignored. Thermal injuries have been described in the
literature secondary to the use of ice packs and other
cooling objects and devices.13 We present the case of a
teenaged athlete who developed vascular compromise of a
nger from a conuent circumferential blister due to an
inappropriately applied commercial cold pack on the
football eld. To our knowledge, no case of vascular
compromise from the blister constriction of digits has been
reported in the literature. The patients legal guardian
provided written informed consent for this case report.
OBJECTIVE

A healthy, 17-year-old, right-handdominant, male high

school football player fell after being tackled, injuring his
right index nger because of contact with the ground. On
the eld, a coach was reported to have applied a
commercially available cooling gel pack, wrapping it
around the athletes nger directly on the skin with an
elastic wrap. The patient did not recall being instructed to
remove it and believed that leaving it on could only help.
After 2 hours, he removed the cooling pack and noticed that
his index nger and the radial half of his uninjured middle

Key Words: constriction syndrome, freezing, cryotherapy,

vascular compromise, hand injuries, ice packs

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Figure 1. A and B, Initial presentation of the nger demonstrating circumferential blister and distal cyanosis.

the underlying tissue. The ngertip was cold, and the distal
phalanx had no capillary rell at that time. His digit was
grossly insensate distal to the blister, and he felt only deep
pressure. The patient held the nger in a partially exed
position and had no gross pain on gentle, passive motion of
the nger. Active range of motion was trace. He had no
isolated band of tissue that created a tourniquet effect; the
entire blister appeared to function as such. The long nger
had a tense blister, which was not circumferential, on the
radial ngertip alone. Sensation and circulation were intact.
No fracture was seen on radiographs. He had no other
injuries.
DIFFERENTIAL DIAGNOSIS

Many conditions or insults can cause blisters or vesicles

to form. Burns, frostbite, and chemical agents can cause
similar-appearing wounds that are differentiated easily if
surrounding circumstances are known. With fractures,
shearing-type insults, and other traumatic injuries, blood
blisters can form secondary to tissue damage. Allergic
reactions or infections also can cause vesicular appearance
and sometimes can create bullae.
Compartment syndrome may present as loss of sensation
to the affected nger or extremity due to inadequate blood
ow. In these cases, entire muscular compartments are
affected by a high-pressure gradient usually from internal
sources, such as bleeding, causing ischemia and necrosis of
the tissues within the compartment. Although these are
characteristically painful, nerve damage or anesthesia may
blunt the discomfort.

TREATMENT

Given the constriction and impending ischemic compromise of the nger, the patient was indicated for emergent
surgical decompression. During the procedure, we longitudinally opened the tensile blisters and released the uid,
thereby decompressing the constriction at the base of the
nger (Figure 2A through C). Given the duskiness of the
nger, approximately 0.5 inches (1.27 cm) of nitroglycerin
paste was placed on the radial and ulnar aspects of the base
of the nger in the constricted area to help vasodilate the
digital vessels. We noted degloving of the epithelium of the
entire index nger distal to the site of constriction. A small
margin of devitalized epithelium was debrided to prevent it
from becoming a secondary source of constriction on the
nger. Given that only the epidermal layer was lifted off by
the blister uid, skin graft was not indicated. The nger
compartments were soft and compressible, and no signs of
compartment syndrome were noted. Finally, use of
intraoperative Doppler ultrasound now conrmed active
perfusion across the constriction site to the tip of the nger
along both the radial and ulnar borders of the nger. If we
had not identied adequate ow, we could have accomplished open vascular exploration and arteriolysis or arterial
bypass. Upon closure, we irrigated the wound and applied
silver sulfadiazine ointment. A wrist-based volar splint was
applied in neutral position. The patient began antibiotics for
prophylaxis, and we conrmed he was immunized against
tetanus.
He started occupational therapy 4 days after the surgical
intervention. At that time, traction splinting was used to
position his index nger in extension using a hook glued to
his ngernail (Figure 2D). Active motion was encouraged

Table. Classification of Freezing Injury5

Classification

Depth

Characteristics

Superficial
First degree
Second degree

Superficial skin involvement

Full-thickness skin involvement

Edema, erythema
Blistering, desquamation

Subcutaneous tissue involvement

Deep tissue involvement

Blue-gray discoloration, hemorrhagic blisters

Deep necrosis to muscle, tendon, bone, etc

Deep
Third degree
Fourth degree

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Volume 49  Number 1  February 2014

Figure 2. A and B, Release of the constriction of the nger. C, The affected nger 2 weeks postinjury. D, Daily exercises with physical
therapy were accomplished with a custom-made splint.

at the metacarpophalangeal and proximal interphalangeal

joints while he was in traction for 6 more days. His dressing
changes included application of silver sulfadiazine to the
open wound. His therapy regimen initially concentrated on
elevation and exercises that included active-assisted range
of motion, later transitioning to active range of motion. He
also had activities that incorporated the use of therapy putty
(AliMed, Inc, Dedham, MA), nger extension, and graspand-pinch exercises modied and graded for pain and nger
circulation. After 24 days, the devitalized skin and the nail
had sloughed off, the underlying skin was pink with good
vascularity, and new nail had begun to emerge. On
postoperative day 25, conditioning and exercise training
was added; however, he felt throbbing in the nger when he
ran. His grip strength was 70% of that of the other hand;
lateral pinch, 52%; and tripod pinch, 47%. On postoperative day 28, his skin was almost completely closed;
however, tenderness to touch persisted, so the gauze
dressing was replaced with a gel polymer digital cap
(Silipos; Isokinetics, Inc, De Queen, AR). On postoperative
day 30, sensory testing indicated complete decit to all
modalities from the distal interphalangeal nger exion
crease distally only on the palmar surface. On postoperative
day 32, he had full extension and exion of all nger joints.
He could catch and throw a football with the digital cap on
the index nger. Dribbling a basketball was uncomfortable.
Running did not cause throbbing, and he no longer had to
keep the nger elevated. On postoperative day 35, his
sensation improved to 2 mm distal to the distal interpha-

langeal crease. He was able to begin jogging and strength

and agility training with the football team by postoperative
day 40. By nal follow-up (postoperative day 46), normal
nail growth had resumed, and sensation of his ngertip had
improved; however, residual sensory decit at the ngertip
persisted. By 10 weeks after surgery, he reported that he
was ready to return to participating in football. He indicated
that his tactile sensation was subjectively adequate to
activities of daily living and sports. He practiced with
caution with the digital gel sleeve under his glove. He had
no restrictions but was instructed to inspect his nger
multiple times throughout participation in sporting activities. In addition, he avoided extremes of temperatures and
carrying thin, hard handles (eg, buckets, plastic grocery
bags) that would stress his interphalangeal joints for about 6
months to protect reinnervation.
DISCUSSION

Fingers are uniquely prone to vascular compromise with

frostbite injuries. Freezing of the digits frequently is
encountered because we often come in contact with cold
surfaces or materials through our interaction with the
environment. We rely so much on hand function that
protecting ngers from the elements during recreational
activities, vocational exposures, or everyday life sometimes
may be difcult. However, given their anatomy, ngers
may be prone to frostbite injuries. Their small size and tight
fascial compartments provide easy paths for warmth to
escape. Furthermore, limited blood supply and little
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collateral circulation put the oxygen supply at risk,

especially with the application of constriction, such as
tight bandages or wraps or, as we saw in our patient, a
commercial cold pack wrapped around the ngers. In
addition to these factors, an adaptation to maintain core
body temperature in a cold environment or, as in our
patient, the local cold affecting the digits may further
reduce nger perfusion as the body shunts blood from the
extremities.
Frostbite injuries are well described in the literature.
Until recently, researchers have not been able to clearly
dene which temperature below freezing produces frostbite. Investigators4 have shown that injury may occur even
after brief nger contact with highly conductive materials
(conductivity close to that of metals) in 3 seconds at the
temperatures of a conventional freezer ( 158C or 58F). As
commercial cooling packs and other cryotherapy devices
become more efcient and powerful, the chances of these
treatments causing more damage than the injury itself are
increased. Melting ice packs (water-ice combinations)
predictably produce a 08C environment and likely decrease
iatrogenic frostbite. However, cooling gel packs and frozen
items (ie, items stored in freezers or ice [not in melting
phase]) may create environments that are below freezing
and may be more dangerous to use.
External insult to the extremities often can affect deep
anatomic structures. Given that constriction syndrome and
compartment syndrome may cause similar abnormalities
and have similar mechanisms, constriction syndrome
implies an external agent that impedes circulation from
reaching the distal parts of the extremity. Constriction
syndrome is a circumferential obstruction, whereas compartment syndrome may involve 1 division (compartment)
or multiple divisions of the extremity. Compartment
syndrome inherently implies an internal pressure gradient
through which blood cannot ow. The nger is a unique
structure because it depends on 2 well-dened but highly
vulnerable digital vessels. Compromise of these vessels by
compression, constriction, or transection will result in
immediate digital ischemia and potential demise of the
digit.
The classication system used for cold injuries according
to severity is similar to the categorization used for burns.
McAdams et al5 explored the once commonly used 4-stage
classication in degrees and rened it for depth of tissue
injury (Table). Cases of rst- and second-degree frostbite
are categorized as supercial insults. They are recognized
by local effects limited to the skin, with advanced forms
causing blisters that later desquamate and form an eschar.
Third- and fourth-degree freezing injuries involve the
subcutaneous tissues and other deep tissues, respectively.
These stages present with hemorrhagic blisters and necrosis
and, eventually, mummied black tissues on the spectrum.
On the microscopic level, cellular damage and physiologic
changes to the changing environment cause tissue destruction. In addition to macroscopic mechanical destruction, ice
crystal formation in the extracellular environment leads to
water shifting outside the cell, causing dehydration and cell
death that progresses to necrosis of the affected tissue bed.6
Inammation, vascular stasis, and thromboses lead to local
ischemia on the cellular level. Understanding the microscopic pathologic process of freezing has helped guide the
development of treatment principles for these injuries.
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Volume 49  Number 1  February 2014

Whereas the general management of freezing injuries

starts with rewarming, the offending cold source in cases of
iatrogenic frostbites most often has been removed before
presentation and the environment has warmed up the
affected area. The protocol for treating frostbite injuries has
been described by Su et al7 based on the initial guide of
management of McCauley et al.8 The authors recommended careful monitoring if the tissue involvement is
supercial. However, according to their treatment scheme,
deep-tissue involvement warrants further investigation and
possible surgical intervention. They used a triple-phase
bone scan at 48 hours and 5 days to delineate blood ow
and viable areas to aid in the debridement efforts by 10
days after initiation of treatment. Some debate has
surrounded the utility of bone scans, and their clinical use
for this purpose has been questioned.9
The management of blisters has been a topic of longstanding debate. Researchers10 have thought that the
contents of these vesicles are similar in composition to
those seen in burns (high in prostaglandins and thromboxanes), so they may predispose surrounding tissues to
ischemia and produce vasoconstrictive effects. The accepted practice is to leave blisters alone unless they are
ruptured, are too tight, or become infected.11 However,
others9 advocate opening the clear vesicles and draining the
hemorrhagic ones to eliminate the potentially damaging
effect of the uid contents. As demonstrated in the
presented case, contiguous vesicles may become so taut
that they may temporarily or permanently cut off
circulation to distal aspects of the digits on the hand.
Thermal injuries due to cold exposure have long been
compared with burn injuries. The mechanism of tissue
injury is similar; the presentation and clinical picture also
coincide. However, the pattern of injury is greatly different
for reasons that may be due to the temporal relationship and
the analgesic and anesthetic effects of the cold item.
Cooling therapy provides hypoalgesic or analgesic effects
locally and possibly centrally by lowering the pain
threshold.12,13 Cryotherapy or contact with other cold
objects may create a dangerous scenario in which the
analgesia locally leads to the inability to feel the pain
associated with the onset of permanent nerve damage.
Other adaptive responses, such as the hunting response of
the extremities, have long been implicated to prevent coldinduced ischemia. This process, also called cold-induced
vasodilatation, has unknown effects on the development of
frostbite injuries of the acral areas.14,15
The presented case demonstrates a unique clinical
consequence of cold injury. Two seemingly distinct
processes led to the substantial morbidity of an otherwise
healthy teenaged athlete. The frostbite led to paresthesia of
the involved digits and disabled the conscious protective
response that usually is mediated by pain to remove the
offending agent (commercial cold pack). This is also likely
the reason the patient did not notice or describe pain,
delaying his presentation to us. The prolonged freezing
caused permanent nerve changes and sensory decit. In
addition, the tissue damage from the freezing induced
blister formation. The blister that propagated circumferentially around the digit created a tourniquet-like
constriction that cut off circulation to the distal portions
of the nger. If the direct, cold-induced nerve damage and
the indirect vascular compromise had not been addressed

urgently, irreversible damage and compromise of the

affected digit might have resulted. The lack of circulation,
as well as frostbite, rst damages the nerves and then the
other tissues. If the injury had been left untreated, further
tissue death might have followed and involved other
structures of the nger, requiring amputation.
Despite widespread use and acceptance of the rest, ice,
compression, and elevation protocol, inadvertent injuries
can happen from improper application of commercial cold
packs. Children may be even more susceptible to these
adverse events. Furthermore, long-term complications in
children have been reported because of the incompletely
developed anatomy and physiology of the affected areas.
When these injuries occur near open growth plates, growth
retardation and physeal arrest may occur.16 Frostbite also
has been implicated in early arthritis of children with a
history of such wounds.17
In the case of circumferential conuent blistering, distal
ischemia may ensue and cause a constriction syndrome,
with vascular and then ischemic changes leading to
irreversible tissue damage. The external circumferential
constraint functions like a tourniquet, which may lead to
insufcient blood ow to the distal structures and requires
immediate surgical release to prevent necrosis and
neurologic dysfunction, as was presented in our case.
UNIQUENESS

In this report, a teenaged athlete developed a prolonged

sensory decit from thermal injury and acute vascular
compromise, requiring urgent operative intervention because of the constriction syndrome caused by the tense
circumferential blister on his nger. The triggering insult
was a commonly available cooling gel pack that many in
the athletic population use.
CONCLUSIONS

Cooling and elevating areas of traumatic injury are

effective and widely used ways to decrease swelling,
erythema, and pain. Clinicians must educate patients and
their caregivers about how to properly use cooling devices,
especially commercial gel packs. As seen in the case
presented, improper icing methods can cause substantial,
long-standing morbidity. Patients with iatrogenic frostbite
injuries need to be evaluated fully, giving particular
attention to neurovascular status, because compromised
circulation can lead to permanent neurologic decit.
Constriction syndrome, in which a peripheral constriction
causes decreased blood ow to the distal aspects of

appendicular structures (eg, ngers, toes), has to be

recognized and the constriction has to be surgically
released, because delay in treatment may carry substantial
morbidity. Proper wrapping techniques that ensure loosetting, intermittent application of cooling devices without
direct skin contact and careful monitoring of the affected
area can prevent serious freezing injuries.
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Address correspondence to Michael Rivlin, MD, Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut
Street, Room 801 Curtis, Philadelphia, PA 19107. Address e-mail to rivlin.md@gmail.com.

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